Behind the Patient: Street Portraits

Remain calm: Assessing and treating panic attacks

Anxiety and emotion can spiral into respiratory compromise that is self-reinforcing, frightening and an EMS-treatable emergency

Some patient encounters are keepers; other experiences need to be forgotten.

Overcoming past calls is one of those skills that nobody teaches you in EMT school. Exorcising the demons that build as the days and weeks of an EMS career build is imperative. One patient complaining of the same thing as another are two entirely different people with potentially two entirely different medical problems.

Of course, the chance always exists that there is actually no problem at all, and therein lies the problem. Bringing the memory of one call to the next disrupts the thinking pattern necessary to be an effective EMT or paramedic.

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Breathing difficulty calls can come one after another. It is one of the most common complaints we respond to. I have fallen into the trap of evaluating a patient based on previous encounters with people complaining of the same problem. Experience taught me to treat each patient as an individual with a unique problem that prompted their call for help. Unfortunately, experience also taught me to put my guard down when responding to emergencies with a history of dubious legitimacy.

Panic attack
An anxiety or panic attack is a very real thing. For the person in the midst of one it is the ONLY thing. The patient is convinced that they are going to die, that there is something wrong with the world’s oxygen supply, that their heart is about to explode and that nobody cares.

Imagine calling for help and after an interminable wait having a condescending, slow moving authority figure come to your aid only to dismiss your complaint as a 'not a real emergency' because they are carrying a pre-conceived assessment of your condition.

To the person having the panic attack, the responder represents salvation. They have been hanging on by the skin of their teeth waiting for help to arrive, and when it does, it doesn’t.

A person having a panic attack needs to be reassured by somebody — anybody — that their problem, though real will not kill them. Or leave them in a coma somewhere full of tubes. They do not need somebody telling them to relax or be harshly told to slow their breathing down. The patient is fully aware that they need to relax, but unfortunately for them their body has other plans. Once the panic mode takes control there is little a person can do to undo it.

You may be tempted to administer oxygen via nasal cannula to a person who is hyperventilating, or find a paper bag and have the patient breathe into it, or worse — one of my favorite tricks until I learned better — apply a non-rebreather mask over the patient’s mouth and neglect to connect the line to the oxygen supply. While this rebreathing strategy is recommended in many emergency medicine manuals and first aid books we know there are risks associated with such treatment.

During hyperventilation, an inadequate level of carbon dioxide is in the blood, and the patient is in respiratory alkalosis. To reverse the condition, the patient needs to slow their breathing down. Giving oxygen to a hyperventilating patient does not cause the situation to get worse, but it will slow the process of returning the blood gases to normal. The cramping, tingling and panic the patient is experiencing is due to this alkalosis.

Trying to explain to a person hyperventilating that they are overbreathing is difficult. The rescuer and the rescuee are speaking completely different languages. It takes time to develop a relationship with the patient, and time is exactly what the patient thinks they are running out of.

I’ve used these steps effectively to resolve a patient's panic attack:

Separate the patient from familiar surroundings.

Separate the patient from familiar people. Especially those who are dramatically fawning and wailing, contributing to the patient's unease.

Establish friendly, confident eye contact with the patient.

Legitimize the emergency. Explain that you understand what is happening to them and know how to help.

Slow your own breathing and exaggerate the sounds of inhalation and exhalation so the patient can hear your breath going in out.

Buckle everybody up and get moving to the ER, no lights or sirens.

Conduct a patient assessment. Answering history questions will help the patient feel at ease while you also consider other medical causes for their hyperventilation.

Trust and rapport give the patient control
More times than not the patient will have resumed normal breathing by the time we arrived at the ER. The patient feels as if they have lost control of their body, and their mind isn’t far behind.

Establishing the trust needed to mitigate a panic attack depends on just about everything we do. Our demeanor is being scrutinized from the second we arrive on scene. Body language is interpreted, and we are being judged. Making the right moves from the start greatly increases the odds of alleviating another person’s misery. Some of my favorite experiences with patients began as calls for "emotional" which turned out to be a panic attack. Guiding a person through the crisis allowed me to see firsthand my effectiveness as an EMT.

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